Valvular heart disease

Question 1

Epidemiology of valvular heart disease (4)

Answer 1

Degenerative valve disease
- reflects ageing population

Rheumatic valve disease

• post strep rheumatic fever
• children and young adults
• disease of poverty and overpopulation

Infective

• Most common on abnormal valves
• immunocompromised

Congenital valve disease
- low, static incidence in all populations

Question 2

Aetiology of valvular heart disease (5)

Answer 2

Degenerative: aortic > mitral

Rheumatic: mitral > aortic

Infective: any valve, right from IVDU

Secondary to loss of supporting structure

Congenital: any valve

Question 3

Pathology

Answer 3

Fibrosis: fusion of leaflets
Calcification: immobility of leaflets
Dilation: of valve ring

Question 4

Stenosis

Answer 4

Narrowing of valve leaflets
Valve leaflets fail to open completely
Leads to build of back pressure and loss of stroke volume

Question 5

Regurgitation

Answer 5

Failure of leaflets to meet in systole
Leaflets fail to close completely
Allows reverse flow of blood during relaxation of the heart

Question 6

Aortic stenosis age of presentation

Answer 6

Congenital (paediatrics, <60)
Bicuspid (40-60 years)
Degenerative (>60)
Post rheumatic fever (<60)

Question 7

Aortic stenosis features

Answer 7

Obstruction to flow

• severe: chest pain, syncope, shortness of breath, fatigue, palpitations
• early: no symptoms

Pressure overload

• high LV pressure
• LV hypertrophy
• eventual LV decompensation/ dilation

Question 8

Aortic stenosis heart sounds

Answer 8

Systolic crescendo/ decrescendo murmur

• doesn’t open so turbulent flow of blood
• pressure rises in systole, peaks then falls

Soft second heart sound
- valve is stiff and thickened so doesn’t close properly

Question 9

Aortic stenosis symptoms

Answer 9

SAD triad: syncope, angina, dyspnoea
Fatigue: decrease in exercise tolerance
Sudden death: rare in asymptomatic, significant risk in symptomatic
Arrhythmias due to pressure overload

Question 10

Aortic regurgitation aetiology

Answer 10

Aortic dilation 
- loss of support
- connective tissue disease
- hypertension aortic dissection, degenerative, cystic medial necrosis, syphilis
Valvular
- bicuspid
- endocarditis

Question 11

Aortic regurgitation consequences

Answer 11

Volume overload: blood falls back into LV during diastole
LV dilation: to acommodate volume, typical result of volume overload
Late decompensation of LV function
High volume circulation: as in pregnancy, anaemia, thyrotoxicosis

Question 12

Aortic regurgitation heart sounds

Answer 12

Early diastolic murmur

• valve leaflets fail to come together
• blood under high pressure in aorta rushes back into the ventricle
• pressure in ventricle lowest at beginning of diastole

Concomitant systolic murur

• aortic valve often structurally abnormal
• turbulence as blood exits ventricle during systole

Question 13

Aortic regurgitation symptoms

Answer 13

Often asymptomatic
Chest pain 
Breathlessness
Syncope- uncommon
Catastrophic decompensation if acute fulminant pulmonary oedema

Question 14

Mitral regurgitation aetiology

Answer 14

Valvular: prolapse, infective, degenerative
Chordal rupture/ papillary muscle failure- acute/ chronic
Annular dilation: secondary to left ventricle dilation

Question 15

Mitral regurgitation consequences

Answer 15

Volume overload in left ventricle: during systole blood ejected back to LA, extra blood in LA means elevation of pressure ao increased LV filling in diastole
Pressure overload of right heart: RV hypertrophy or right heart failure
Left ventricular dilation: response to volume overload
Decompensation: pulmonary oedema

Question 16

Mitral regurgitation heart sounds

Answer 16

Pan-systolic murmur:

• leaflets fail to coapt
• blood leaks back to LA with turbulence
• occurs for whole of sytsole

Question 17

Mitral regurgitation symtpoms

Answer 17

Breathlessness due to back pressure of pulmonary circulation
Lethargy and reduced exercise tolerance
Palpitations
Peripheral oedema
Chest pain

Question 18

Mitral valve prolapse

Answer 18

Leaflet is too baggy or abnormal valvular apparatus
Leaflet prolapses back into LA
Allows through jet of regurgitation

Question 19

Mitral valve prolapse heart sounds

Answer 19

Mid systolic click:
- leaflets prolapse back into the LA

Late systolic murmur:
- blood continues to flow into LA after initial jet of regurgitation

Question 20

Mitral stenosis aetiology (7)

Answer 20

1. almost always due to rheumatic fever
2. congenital
3. storage disease
4. malignancy
5. previous endocarditis
6. mitral valve calcification
7. systemic disease

Question 21

Mitral stenosis consequences

Answer 21

Lung/ right heart consequences:

• breathlessness, congestion
• due to pressure back up because of failure of ejection of left atrial volume

Left ventricle physiology usually preserved
- LV function compromised when atrial contraction lost or high circulating volume

Question 22

Mitral stenosis heart sounds

Answer 22

Mid diastolic rumbling
- stenosis restricts blood flowing across mitral valve from LA to LV

Opening snap
- as the restricted leaflets snap open

Loud first heart sounds

• leaflets are stiff but still relatively mobile
• leaflets slam shut

Question 23

Mitral stenosis symptoms

Answer 23

Lungs: breathlessness, peripheral oedema, haemoptysis
Palpitations
Systemic emboli
Fatigue
Compressive symptoms: stridor, dysphagia

Question 24

Trans-cutaneous valve replacement

Answer 24

Aortic: new technology, patients considered high risk for AVR, procedures under local anaesthetic , shorter recovery time

Mitral valve: mitraclip